American Urological Association (AUA)

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Approved by the AUA Board of Directors April 2016

Authors' disclosure of potential conflicts of interest and author/staff contributions appear at the end of the article.

? 2016 by the American Urological Association

American Urological Association (AUA)

Endourological Society Guideline

SURGICAL MANAGEMENT OF STONES: AMERICAN UROLOGICAL ASSOCIATION/ ENDOUROLOGICAL SOCIETY GUIDELINE

Dean Assimos, MD; Amy Krambeck, MD; Nicole L. Miller, MD; Manoj Monga, MD; M. Hassan Murad, MD, MPH; Caleb P. Nelson, MD, MPH; Kenneth T. Pace, MD; Vernon M. Pais Jr., MD; Margaret S. Pearle, MD, Ph.D; Glenn M. Preminger, MD; Hassan Razvi, MD; Ojas Shah, MD; Brian R. Matlaga, MD, MPH

Purpose

The purpose of this Guideline is to provide a clinical framework for the surgical management of patients with kidney and/or ureteral stones.

Methods

A systematic review of the literature using the Medline In-Process & Other NonIndexed Citations, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus databases (search dates 1/1/1985 to 5/31/15) was conducted to identify peer-reviewed studies relevant to the surgical management of stones. The review yielded an evidence base of 1,911 articles after application of inclusion/exclusion criteria. These publications were used to create the guideline statements. If sufficient evidence existed, then the body of evidence for a particular treatment was assigned a strength rating of A (high quality evidence; high certainty), B (moderate quality evidence; moderate certainty), or C (low quality evidence; low certainty). Evidence-based statements of Strong, Moderate, or Conditional Recommendation, which can be supported by any body of evidence strength, were developed based on benefits and risks/burdens to patients. Additional information is provided as Clinical Principles and Expert Opinions when insufficient evidence existed.

Guideline Statements

Imaging, pre-operative testing:

1. Clinicians should obtain a non-contrast CT scan on patients prior to performing PCNL. Strong Recommendation; Evidence Level Grade C

2. Clinicians may obtain a non-contrast CT scan to help select the best candidate for SWL versus URS. Conditional Recommendation; Evidence Level Grade C

3. Clinicians may obtain a functional imaging study (DTPA or MAG-3) if clinically significant loss of renal function in the involved kidney or kidneys is suspected. Conditional Recommendation; Evidence Level Grade C

4. Clinicians are required to obtain a urinalysis prior to intervention. In patients with clinical or laboratory signs of infection, urine culture should be obtained. Strong Recommendation; Evidence Level Grade B

5. Clinicians should obtain a CBC and platelet count on patients undergoing procedures where there is a significant risk of hemorrhage

Copyright ? 2016 American Urological Association Education and Research, Inc.?

American Urological Association (AUA) Endourological Society Guideline

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Surgical Management of Stones

or for patients with symptoms suggesting anemia, thrombocytopenia, or infection; serum electrolytes and creatinine should be obtained if there is suspicion of reduced renal function. Expert Opinion

6. In patients with complex stones or anatomy, clinicians may obtain additional contrast imaging if further definition of the collecting system and the ureteral anatomy is needed. Conditional Recommendation; Evidence Level Grade C

Treatment of adult patients with ureteral stones:

7. Patients with uncomplicated ureteral stones 20 mm, clinicians should offer PCNL as first -line therapy. (Index Patient 8) Strong Recommendation; Evidence Level Grade C

25. In patients with total renal stone burden >20 mm, clinicians should not offer SWL as first-line therapy. (Index Patient 8) Moderate Recommendation; Evidence Level Grade C

27. Clinicians may perform nephrectomy when the involved kidney has negligible function in patients requiring treatment. (Index Patients 1-14) Conditional Recommendation; Evidence Level Grade C

28. For patients with symptomatic (flank pain), non-obstructing, caliceal stones without another obvious etiology for pain, clinicians may offer stone treatment. (Index Patient 12) Moderate Recommendation; Evidence Level Grade C

29. For patients with asymptomatic, non-obstructing caliceal stones, clinicians may offer active surveillance. Conditional Recommendation; Evidence Level Grade C

30. Clinicians should offer SWL or URS to patients with symptomatic 10 mm lower pole renal stones. (Index Patient 9) Strong Recommendation; Evidence Level Grade B

31. Clinicians should not offer SWL as first-line therapy to patients with >10mm lower pole stones. (Index Patient 10) Strong Recommendation; Evidence Level Grade B

32. Clinicians should inform patients with lower pole stones >10 mm in size that PCNL has a higher stone -free rate but greater morbidity. (Index patient 10). Strong Recommendation; Evidence Level Grade B

33. In patients undergoing uncomplicated PCNL who are presumed stone-free, placement of a nephrostomy tube is optional. Conditional Recommendation; Evidence Level Grade C

34. Flexible nephroscopy should be a routine part of standard PCNL. Strong Recommendation; Evidence Level Grade B

35. Clinicians must use normal saline irrigation for PCNL and URS. Strong Recommendation; Evidence Level Grade B

39. In patients not considered candidates for PCNL, clinicians may offer staged URS. Moderate Recommendation; Evidence Level Grade C

40. Clinicians may prescribe -blockers to facilitate passage of stone fragments following SWL. Moderate Recommendation; Evidence Level Grade B

43. SWL should not be used in the patient with anatomic or functional obstruction of the collecting system or ureter distal to the stone. Strong Recommendation; Evidence Level Grade C

44. In patients with symptomatic caliceal diverticular stones, endoscopic therapy (URS, PCNL, laparoscopic, robotic) should be preferentially utilized. Strong Recommendation; Evidence Level Grade C

45. Staghorn stones should be removed if attendant comorbidities do not preclude treatment. Clinical Principle

Copyright ? 2016 American Urological Association Education and Research, Inc.?

American Urological Association (AUA) Endourological Society Guideline

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Surgical Management of Stones

Treatment for pediatric patients with ureteral or renal stones:

46. In pediatric patients with uncomplicated ureteral stones 10 mm, clinicians should offer observation with or without MET using -blockers. (Index Patient 13) Moderate Recommendation; Evidence Level Grade B

47. Clinicians should offer URS or SWL for pediatric patients with ureteral stones who are unlikely to pass the stones or who failed observation and/or MET, based on patient-specific anatomy and body habitus. (Index Patient 13) Strong Recommendation; Evidence Level Grade B

48. Clinicians should obtain a low-dose CT scan on pediatric patients prior to performing PCNL. (Index Patient 13) Strong Recommendation; Evidence Level Grade C

49. In pediatric patients with ureteral stones, clinicians should not routinely place a stent prior to URS. (Index Patient 13) Expert Opinion

50. In pediatric patients with a total renal stone burden 20mm, clinicians may offer SWL or URS as first -line therapy. (Index Patient 14) Moderate Recommendation; Evidence Level Grade C

51. In pediatric patients with a total renal stone burden >20mm, both PCNL and SWL are acceptable treatment options. If SWL is utilized, clinicians should place an internalized ureteral stent or nephrostomy tube. (Index Patient 14) Expert Opinion

52. In pediatric patients, except in cases of coexisting anatomic abnormalities, clinicians should not routinely perform open/laparoscopic/robotic surgery for upper tract stones. (Index Patients 13, 14) Expert Opinion

53. In pediatric patients with asymptomatic and non-obstructing renal stones, clinicians may utilize active surveillance with periodic ultrasonography. (Index Patient 14) Expert Opinion

Treatment for pregnant patients with ureteral or renal stones:

54. In pregnant patients, clinicians should coordinate pharmacological and surgical intervention with the obstetrician. (Index Patient 15) Clinical Principal

55. In pregnant patients with ureteral stones and well controlled symptoms, clinicians should offer observation as first-line therapy. (Index Patient 15) Strong recommendation; Evidence Level Grade B

56. In pregnant patients with ureteral stones, clinicians may offer URS to patients who fail observation. Ureteral stent and nephrostomy tube are alternative options with frequent stent or tube changes usually being necessary. (Index Patient 15) Strong Recommendation; Evidence Level Grade C

Treatment for all patients with ureteral or renal stones:

23. When residual fragments are present, clinicians should offer patients endoscopic procedures to render the patients stone free, especially if infection stones are suspected. (Index Patient 11) Moderate Recommendation; Evidence Level Grade C

24. Stone material should be sent for analysis. Clinical Principle

26. Open/ laparoscopic /robotic surgery should not be offered as first-line therapy to most patients with stones. Exceptions include rare cases of anatomic abnormalities, with large or complex stones, or those requiring concomitant reconstruction. (Index Patients 1-15) Strong Recommendation; Evidence Level Grade C

36. A safety guide wire should be used for most endoscopic procedures. (Index Patients 1-15) Expert Opinion

37. Antimicrobial prophylaxis should be administered prior to stone intervention and is based primarily

Copyright ? 2016 American Urological Association Education and Research, Inc.?

American Urological Association (AUA) Endourological Society Guideline

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Surgical Management of Stones

on prior urine culture results, the local antibiogram, and in consultation with the current Best Practice Policy Statement on Antibiotic Prophylaxis. Clinical Principle

38. Clinicians should abort stone removal procedures, establish appropriate drainage, continue antibiotic therapy, and obtain a urine culture if purulent urine is encountered during endoscopic intervention. (Index Patients1-15) Strong Recommendation; Evidence Level Grade C

41. If initial SWL fails, clinicians should offer endoscopic therapy as the next treatment option. (Index Patient 1-14) Moderate Recommendation; Evidence Level Grade C

42. Clinicians should use URS as first-line therapy in most patients who require stone intervention in the setting of uncorrected bleeding diatheses or who require continuous anticoagulation/antiplatelet therapy. (Index Patients1-15) Strong Recommendation; Evidence Level Grade C

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